Job Summary:Oversees audits/investigations and audit/investigation workload. Performs in-depth evaluation and makes field level judgments related to audits/investigations of potential Medicare fraud waste and abuse audits/investigations or cases compliance cases (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or to law enforcement for criminal action.
Essential Functions:- Reviews new audits/investigations and/or incoming leads to determine appropriateness and assigns to auditors/investigators; vets providers as required with appropriate agency(ies) and law enforcement; supervises vetting process. Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to team.
- Conducts file reviews regularly of audits/investigations to ensure audit/investigation plan is appropriate and the audit/investigation file documents are entered and summarized within the case tracking systems appropriately. Reviews auditor/investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness.
- Supervises and conducts audit/investigation actions such as interviewing, onsite audit/investigation, and/or site verification as needed. Leads audit/investigation projects including developing an audit/investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management.
- Communicates with the Data and Medical Review departments to ensure efficient audits/investigations. Prepares and presents audits/investigations, overpayments, and questions for stakeholder meetings.
- Documents audit/investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed. Determines audit/investigation appropriateness of fraud, waste, and abuse issues in accordance with pre-established criteria. Reviews audit/investigative findings with auditors/investigators and approves course of action. Supervises and prepares team's audits/investigations for the Major Case Coordination meetings and reviews for quality assurance.
- Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting audit/investigation findings for their consideration to further audit/investigate, prosecute, or seek other appropriate regulatory or administrative remedies. Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions, revocations, provider education) and reviews for quality assurance. Reviews and approves closing summary of audit/investigation.
- Collects information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submits, as required.
- Collaborates with other program integrity contractors, as needed.
- Testifies at various legal or administrative proceedings, as necessary.
- Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
Level of Supervision Received:Drives work independently and escalates questions and issues, as needed
Education (can be substituted for experience):Minimum Bachelor's Degree required
Work Experience (can be substituted for education):5 - 7 years of experience required; 8 - 11 years preferred
Certification(s):Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred
